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Paint & Persevere - 1st & 3rd Mondays
This is a confidential form. 
Please complete the questions below as part of our brief initial screening and insurance verification. After completion of this form, we will contact you via phone call, email, and/or text message to confirm your spot in the group.

Group Details

📅 Date: 1st & 3rd Mondays, starting July. 20th 
⌚Time: 5:30-7:30pm
📍Location: Anchor Within Counseling - Conference Room

Anchor Within Counseling
www.anchorwithincounseling.com
Email *
Legal Name of Client *
Client Date of Birth *
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Age Group of Prospective Client *
Race/Ethnicity of prospective client *
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If Prospective Client is a minor, please give parent/guardian name
Preferred email address *
Preferred phone number *
Insurance *
Insurance Member ID:
Have you been, or are you currently, under the care of a psychiatrist? *
Have you been hospitalized for mental health reasons in the last 12 months? *
Are you a current or previous client of Anchor Within Counseling? *
How did you hear about us? *
I agree to the Core Principles of Group Care at Anchor:

Confidentiality: What is said in the group stays in the group. This is the cornerstone of trust and safety. I agree not to share personal information about other members outside of the group setting.

Respect: I agree to treat all group members and the providers with respect. This includes listening without interrupting and being mindful of different perspectives.

Active Participation: I understand that this is my time to work on my goals in a collaborative space. I will be encouraged to share my thoughts, feelings, and experiences, as well as to provide support and feedback to others.

Commitment to the Group: I commit to attend sessions regularly and be on time. I understand that the group will begin on-time whether I arrive on-time or not. If I need  to miss a session, I will let the provider(s) know in advance, as much as is possible.

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